Reducing Deaths by Diet: A Call for Public Policy to Prevent Chronic

Clinical Medicine: Arts and Sciences
Reducing Deaths by Diet: A Call for
Public Policy to Prevent Chronic Disease
Norm Campbell CM, MD, FRCPC, Michel Sauvé MD FRCP FACP FCCP MSc
About the Authors
Norm Campbell CM MD FRCPC is with the Division of General Medicine,
Community Health Sciences and Physiology and Pharmacology and is a member of the
O’Brien Institute of Public Health and Libin Cardiovascular Institute of Alberta at the
University of Calgary in Alberta. Michael Sauve is with the Northern Lights Regional
Health Centre in Fort McMurray, Alberta.
Correspondence may be directed to [email protected].
Introduction
Chronic diseases including cardiovascular disease and cancer
are the leading causes of disability and death in Canada.1,2 The
majority of chronic diseases are caused by physical inactivity,
tobacco use, excess alcohol consumption and unhealthy diet.3-6
In particular, unhealthy diet is the leading risk factor for death
and disability in Canada resulting in an estimated 64,000
deaths and over 1 million years of disability (DALYs) in 2010
alone.7 Worldwide, a staggering 11 million deaths and over 200
million DALYs were attributed to unhealthy eating in 2010.
The usual Canadian diet is unhealthy, high in saturated
fat, trans-fats, free sugars, and salt and low in fresh fruit,
whole-grains, and vegetables (including legumes /beans).8-12
An estimated 30,000 deaths could be delayed annually if our
diets complied with Canadian dietary recommendations,
particularly for fruit, and vegetable intake.13 In fact, the
estimated risk of cardiovascular disease is reduced by about
4% and total premature death rate reduced by 6-7% for each
additional serving of fruit and vegetable daily.14
The World Health Organization (WHO) advocates
population approaches to achieve healthy diets as being critical
to reduce non-communicable diseases (NCDs). The United
Nations has established 9 targets to halt the rise in chronic
disease including stopping the increase in obesity, reducing
uncontrolled hypertension by 25% and reducing dietary salt by
30% by 2025.5 Many countries are implementing populationbased policies to reduce dietary risk with success; however,
Canadian approaches focus largely on individual behavior
change.6 In contrast, Canadian governmental and nongovernmental chronic disease strategies strongly recommend
population-based interventions to improve diet.17-20 However,
few effective population-based interventions to improve diet
have been implemented to date. While individual behaviour
Canadian Journal of General Internal Medicine
Campbell
Sauvé
choices are clearly important, it is unlikely that substantive
progress will be made without a comprehensive set of
population-based interventions to facilitate healthy choices
being feasible and easy for individuals to make.16
Introduction
Les maladies chroniques, dont les affections cardiovasculaires et
le cancer, sont les principales causes d’incapacité et de mortalité
au Canada1,2. La plupart des maladies chroniques résultent de
l’inactivité physique, de l’usage du tabac, de la consommation
excessive d’alcool ou d’une mauvaise alimentation3-6. Plus
particulièrement, en 2010 seulement, la mauvaise alimentation
a été le principal facteur de risque de mortalité et d’incapacité
au Canada, en causant environ 64 000 décès et plus d’un million
d’années de vie ajustée en fonction de l’incapacité (AVAI)7. À
l’échelle mondiale, toujours en 2010, on attribue les nombres
ahurissants de 11 millions de décès et de plus de 200 millions
d’AVAI en raison de la mauvaise alimentation.
Le régime alimentaire canadien courant s’avère malsain,
riche en gras saturés, en gras trans, en sucre libres et en sel,
en plus d’être pauvre en fruit frais, en grains entiers et en
légumes (incluant les légumineuses)8-12. Environ 30 000 vies
pourraient être prolongées annuellement si notre alimentation
respectait les recommandations du Guide alimentaire
canadien, notamment en matière de consommation de fruits
et de légumes13. En fait, on estime que l’ajout quotidien d’une
portion de fruits ou de légumes au régime alimentaire fait
diminuer le risque de maladie cardiovasculaire d’environ 4 %
et le taux de décès prématuré de 6 à 7 %14.
L’Organisation mondiale de la santé (OMS) défend l’idée
que les méthodes axées sur la population pour instaurer de
saines habitudes alimentaires sont essentielles à la réduction du
nombre de cas de maladies non transmissibles. Dans le but de
freiner l’augmentation des maladies chroniques, l’Organisation
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Reducing Deaths by Diet
des Nations Unies a fixé neuf objectifs à atteindre d’ici 2025,
dont l’arrêt de la progression de l’obésité, la réduction de
25 % du nombre de cas d’hypertension non normalisée et une
baisse de 30 % de la consommation de sel5. En vue de réduire
les risques liés à la mauvaise alimentation, nombre de pays
instaurent avec succès des politiques axées sur la population,
pendant qu’au Canada les méthodes actuelles se concentrent
plutôt sur le changement des comportements individuels6.
En revanche, les stratégies canadiennes gouvernementales
et non gouvernementales relatives aux maladies chroniques
recommandent fortement la mise en œuvre de politiques de
population pour favoriser une meilleure alimentation17-20. Par
contre, peu de ces interventions ont été mises en place à ce jour.
Il est clair que les choix de comportements individuels sont
importants, mais il est peu probable que les choses s’améliorent
de façon significative sans l’instauration d’un ensemble de
mesures axées sur la population en général et permettant aux
individus de faire des choix sains plus facilement16.
A National Health Sector Response
Over 15 Canadian health-related organizations, including the
Canadian Society of Internal Medicine, have supported a Call
to Action to Implement a Healthy Food Policy Agenda.21
Based on international recommendations, the Call
advocates key components of a comprehensive food strategy
that could meaningfully reduce the diet-related chronic disease
including:3,5,6,8,15,21,22
• restricting the marketing of foods and beverages to
children.
• regulating the additions of sodium, free-sugars, and transfats in processed foods.
• promoting intake of whole grains, fruits and vegetables
including legumes/beans.
• promoting the reduction of saturated fats in our diet.
• establishing simple easy-to-understand nutrition labeling
on processed food products and in dining establishments
• introducing targeted subsidies for healthy food products
combined with taxation of unhealthy food/beverage
products.
Advocacy Opportunities
General Internists are important opinion leaders and can play
strong advocacy roles. All levels of Canadian government
have the authority to impact healthy and unhealthy diets
through public policy; however, Canada’s health and scientific
organizations, the private sector, and individuals all need to
play important roles.
To the extent that chronic disease represents the greatest
burden of diet-related disease managed in adults by General
Internists, we have an important opportunity to advocate at
the clinical and public health level. This can start by supporting
national calls to action for governments to respond and act.
The impact of poor diet on premature morbidity and mortality
should be a focus in all internal medicine academic and
education-related endeavors, including publications. Likewise,
Internists can advocate for more research funding to assess and
monitor dietary trends and the impact of nutrition policy on
public health outcomes to inform future research and policy
priorities.
Canadian policy responses to diet-related death and
disability are inadequate and are falling behind those of other
countries. Recently five key messages were proposed to be the
basis for unified action on obesity.16 The messages recognize:
1) that the epidemic of diet-related chronic disease will not
be reversed without strong government leadership.
2) the status quo will be costly in terms of population
health, health care expenses, and loss of productivity.
3) there is limited impact and low sustainability of
education efforts aimed at the individual level.
4) there is a need to accurately monitor and evaluate
population nutrition data and intervention outcomes.
5) that a multi-sectoral systems approach is needed.
Canadian policies are lagging behind the global community
in response to the increasing burden of chronic disease. The
time is now for Canadian General Internists to play a stronger
role in reversing this trend.
• implementing healthy food and beverage procurement
policies in publicly-funded and private sector settings.
• developing standards to reduce conflicts of interest in
nutrition policy development, research and education.
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Campbell
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